Non-Pharmacological Interventions for Chronic Pain Management: A Narrative Review

Introduction

Chronic pain is a pervasive and debilitating state that affects millions of people globally, causing significant distress, disability, and economic bur- den. Characterized by persistent and recurring pain lasting beyond three months, it can profoundly im- pact an individual's quality of life, mental health, and socioeconomic well-being [1]. The prevalence of chronic pain varies widely, with estimates sug- gesting that it affects approximately 30% of the global population. Another report estimates that more than 100 million adults are affected by chronic pain, resulting in substantial economic and healthcare burdens [2]. The complex aetiology of chronic pain involves multiple factors, including biological, psychologi- cal, and social components. Biological causes in- clude tissue damage, inflammation, and genetic predisposition. Moreover, multiple types of injury or infection can lead to the activation of nocicep- tors [3]. Additionally, chronic pain can be caused by underlying medical conditions, such as arthritis, fibromyalgia, or neuropathic pain [4]. Traditionally, the management of chronic pain has relied heavily on pharmacological interventions— primarily opioid analgesics. While these medica- tions can offer temporary pain relief, they are asso- ciated with significant risks, including addiction, dependence, respiratory depression, and gastroin- testinal complications. Prolonged opioid use can also lead to tolerance and even paradoxical in- creases in pain sensitivity, known as opioid-in- duced hyperalgesia [5]. Recognizing the limitations and potential risks as- sociated with pharmacological approaches, there has been a growing emphasis on non-pharmacolog- ical interventions to manage chronic pain. These encompass a diverse range of approaches, each tar- geting different aspects of the pain experience and aiming to improve overall function and well-being.

Therapies, such as physical therapy and occupa- tional therapy, employ a variety of techniques, in- cluding manual therapy, therapeutic exercises, and modalities such as transcutaneous electrical nerve stimulation (TENS), to improve physical function, reduce pain, and enhance movement patterns [6]. Psychological therapies, such as cognitive behav- ioural therapy (CBT) and mindfulness-based stress reduction (MBSR), focus on addressing the psy- chological and emotional aspects of chronic pain. These therapies help individuals identify and mod- ify maladaptive thoughts and behaviours, develop coping strategies, manage pain-related anxiety and depression, and improve their overall well-being [7]. Complementary and integrative medicine (CIM) modalities, including yoga, Tai Chi, acupuncture, and massage therapy, offer a holistic approach to pain management. These practices can help reduce stress, improve sleep quality, enhance flexibility, and promote overall physical and mental well-be- ing [8]. This comprehensive review aims to critically eval- uate the efficacy and safety of various non-pharma- cological interventions for chronic pain manage- ment. By synthesizing the available evidence from rigorous clinical trials, meta-analyses, and system- atic reviews, it will provide clinicians, researchers, and sufferers of chronic pain with valuable insights into the most effective and evidence-based ap- proaches to manage this complex condition.

Methods

A systematic search strategy was employed to iden- tify relevant studies published in peer-reviewed journals. The search encompassed a broad range of databases, including PubMed, Scopus, CINAHL, and Web of Science. Keywords related to both chronic pain and non- pharmacological interventions were meticulously selected and combined using Boolean operators (AND, OR, NOT) to refine the search results. These keywords included, but were not limited to: "chronic pain," "pain management", "non-pharma- cological", "physical therapy", "occupational ther- apy", "exercise therapy", "cognitive behavioral therapy", "mindfulness", "yoga", "Tai Chi", "acu- puncture", "massage", "manual therapy", "spinal manipulation", and "mind-body therapies". The search was limited to studies published in English within the previous 25 years (2000-2024) to ensure

the inclusion of the most recent and relevant evi- dence. Inclusion criteria for the studies were as follows: Study design: Randomized controlled trials (RCTs), controlled clinical trials, systematic re- views, cohort studies, and case-control studies were considered. Population: Studies involving adult participants with chronic pain conditions were included. Interventions: Studies were eligible if they investi- gated non-pharmacological interventions for chronic pain management, including physical ther- apies, psychological therapies, and complementary and integrative medicine modalities. Outcomes: Studies that reported on relevant out- comes, such as pain intensity, interference with daily activities, effect on quality of life, and ad- verse events, were included. Exclusion criteria: Study design: Case reports, case series, and animal studies were excluded. Population: Studies involving populations with acute pain were excluded. Interventions: Studies investigating pharmacologi- cal interventions or surgical procedures were ex- cluded. Outcomes: Studies that did not report on relevant clinical outcomes were excluded. The extracted data were narratively synthesized to provide a comprehensive overview of the effective- ness and safety of various non-pharmacological in- terventions for chronic pain management. This rig- orous methodology ensured the inclusion of high- quality evidence and provided a robust foundation for this narrative review.

Results

The focus of this narrative review was the efficacy and safety of various non-pharmacological interventions for chronic pain management. The examined interventions, categorized as physical therapies, occupational therapy, psychological therapies, or complementary and integra- tive medical practices (CIM), are discussed below. 1. Physical Therapies Physical therapies can be broadly categorized into man- ual therapy, exercise therapy, and therapeutic modali- ties [9]. 1.1 Manual Therapy Common manual therapy techniques involve joint mo- bilization and manipulation, whereby precisely cali- brated biomechanical forces are judiciously applied to articular structures. The objective of such interventions

is to optimize arthrokinematic integrity and modulate afferent nociceptive pathways. Joint mobilization, often using graded oscillatory movements or sustained artic- ular glides, aims to restore accessory joint motion and mitigate capsular restrictions. Conversely, manipulative interventions, typified by high-velocity, low-amplitude thrusts (HVLAT), such as those employed in spinal ma- nipulative therapy, are posited to elicit neurophysiolog- ical responses, including segmental reflex inhibition and descending pain modulation, thereby attenuating al- logenic signalling [10]. Soft tissue mobilization (STM) involves manual modal- ities targeting myofascial, tendinous, and ligamentous structures to mitigate aberrant myofascial hypertonicity, deactivate trigger points, and enhance tissue compli- ance. Techniques include myofascial release, trigger point deactivation, and deep tissue effleurage. Special- ized methods such as strain-counterstrain (SCS) attenu- ate proprioceptive input and myospasm via passive po- sitioning, while muscle energy techniques (METs) lev- erage volitional contraction to restore arthrokinematic freedom. The empirical evidence for the efficacy of manual therapy is heterogeneous. While spinal manipu- lative therapy (SMT) shows utility for specific lumbago presentations, the evidentiary basis for many techniques within the broader category of soft tissue mobilization (STM)—such as myofascial release and muscle energy techniques—remains less conclusive [11]. 1.2 Exercise Therapy Diversified exercise modalities encompassing aerobic conditioning (e.g., ambulation, aquatic ergometry, cy- cling) contribute to enhanced cardiorespiratory fitness and systemic antinociception; resistance training, me- ticulously targeting specific myoskeletal units, aug- ments muscular strength and joint stability; flexibility regimens, including static and dynamic stretching and range-of-motion protocols, optimize articular excursion and mitigate myofascial rigidity; and functional move- ment patterns, mirroring activities of daily living, en- hance overall functional capacity. Robust empirical ev- idence substantiates the therapeutic efficacy of exercise therapy across a spectrum of chronic pain phenotypes. For instance, meta-analyses and systematic reviews consistently demonstrate significant improvements in pain intensity, physical function, and health-related quality of life in conditions such as chronic low back pain, fibromyalgia, and knee osteoarthritis. The mecha- nisms posited include modulation of central sensitiza- tion, activation of endogenous opioid systems, reduc- tion of systemic inflammatory markers, and promotion of beneficial neuroplastic changes within pain pro- cessing networks. The prescription of exercise must be individualized, considering principles of progressive overload, specificity, and patient-specific pain neuro- physiology, to optimize therapeutic outcomes [12,13].

1.3 Therapeutic Modalities Therapeutic modalities employed in pain management include transcutaneous electrical nerve stimulation (TENS) for nociceptive modulation, therapeutic ultra- sound for thermal and non-thermal cellular effects, su- perficial thermotherapy (e.g., moist heat, cryotherapy) for local perfusion and metabolic alteration, and low- level laser therapy (LLLT) for photobiomodulation. Empirical evidence varies regarding their efficacy; TENS may offer transient antinociception, but evidence remains less robust for the sustained utility of modali- ties such as therapeutic ultrasound in chronic pain man- agement [14]. Important Considerations for Physical Therapy: Optimal physical therapy regimens require meticu- lous individualization, considering the patient's unique pathophysiological profile, specific chronic pain phenotype, and extant biomechanical con- straints. The synergistic integration of diverse physical therapeutic techniques, such as manual therapy, exercise prescription, and various electro- physical modalities, is often demonstrably more ef- fective than monotherapy. Psychoeducation, en- compassing didactic instruction on pain neurobiol- ogy and the implementation of self-effective pain management strategies, constitutes an indispensa- ble facet of comprehensive physical therapy. Fur- thermore, exercise programs must be entail pro- gressive overload, with incremental titration of load and complexity contingent on the patient's evolving physiological adaptation and functional restoration [15]. 2. Occupational Therapy Occupational therapy (OT) for chronic pain pri- marily involves meticulous activity analysis and modification to identify pain exacerbators and for- mulate adaptive task execution strategies, thereby mitigating biomechanical strain. Occupational therapists also prescribe and train patients in assis- tive technology and adaptive equipment to facili- tate independent performance of instrumental ac- tivities of daily living (IADLs) with reduced dis- comfort. Energy conservation techniques, encom- passing activity pacing and strategic rest, are im- parted to optimize functional endurance and pre- clude pain exacerbations [16]. Furthermore, OT in- corporates joint protection principles and compre- hensive pain management psychoeducation, providing an advanced understanding of pain neu- roscience, cognitive/behavioral coping mecha- nisms, and self-management paradigms.

Although the empirical efficacy of OT demon- strates variability based on intervention and pain phenotype [16,17], it remains a valuable compo- nent of a multidisciplinary pain management ap- proach. 3. Psychological Therapies Several psychological therapies have demonstrated significant therapeutic efficacy in the management of chronic pain, notably those encompassing cog- nitive behavioural therapy (CBT), mindfulness- based stress reduction (MBSR), and acceptance and commitment therapy (ACT) [18]. 3.1 Cognitive Behavioural Therapy (CBT) Cognitive behavioural therapy (CBT) for chronic pain typically involves cognitive restructuring, which facilitates the identification and challenge of maladaptive cognitions, such as pain-related catastrophizing or beliefs in functional incapacita- tion. This process aims to foster cognitive reap- praisal and the development of more adaptive sche- mas. Autonomic regulation strategies, including di- aphragmatic breathing, progressive neuromuscular relaxation, and guided affective imagery, are fre- quently employed to attenuate somatic hyper- arousal and mitigate pain-related anxiety. Behav- ioural activation constitutes another pivotal compo- nent, encouraging patients to incrementally aug- ment participation in value-concordant and rein- forcing activities, even in the presence of persistent pain, thereby countering activity avoidance and ameliorating affective dysregulation. Finally, adap- tive pain self-management strategies are imparted to modulate acute pain exacerbations, encompass- ing activity pacing, cognitive distraction tech- niques, and continued autonomic regulation exer- cises. CBT has been extensively investigated and is an established first-line psychological intervention for chronic pain [19]. Meta-analyses, notably by Hofmann et al., have demonstrated its robust effi- cacy in attenuating pain perception, enhancing functional restoration, and ameliorating psycholog- ical morbidity across heterogeneous chronic pain phenotypes. Furthermore, empirical data indicate the particular utility of CBT for individuals with distinct chronic pain etiologies [20]. 3.2 Mindfulness-Based Stress Reduction (MBSR) Mindfulness-based stress reduction (MBSR) for chronic pain typically involves contemplative prac- tices such as body scan meditation, seated mindful-

ness, and ambulatory meditation. Informal integra- tion of mindfulness into daily activities, such as mindful eating and walking, is also cultivated. The incorporation of hatha yoga and somatic awareness exercises is common, aiming to enhance intercep- tive awareness and reduce musculoskeletal tension. MBSR has demonstrated efficacy in attenuating pain perception, improving affective states, and fostering pain acceptance in individuals with chronic pain, and there is robust evidence for its ca- pacity to reduce pain catastrophizing and enhance health-related quality of life in specific chronic pain conditions. Comprehensive reviews conclude that MBSR may serve as a valuable adjunct to ex- isting pain management paradigms [21]. 3.3 Acceptance and Commitment Therapy (ACT) Acceptance and commitment therapy (ACT) aims to address chronic pain through psychological ac- ceptance, which involves the volitional embrace of internal experiences, including persistent pain, without judgment or experiential avoidance. Cog- nitive diffusion, a core process, involves disengag- ing from the literal content of unhelpful thoughts about pain, recognizing them as transient mental phenomena rather than objective truths. Values clarification, the explicit articulation of deeply held personal principles, guides therapeutic direction. Finally, committed action entails engaging in be- haviours aligned with these identified values, even in the presence of discomfort, thereby fostering psychological flexibility and functional engage- ment. ACT has demonstrated efficacy in enhancing functional capacity and health-related quality of life in individuals with chronic pain, even in the ab- sence of significant changes in pain intensity. Stud- ies have indicated the effectiveness of ACT in im- proving psychological flexibility and reducing pain interference, as well as its particular utility for chronic pain patients grappling with pain-related anxiety [22]. 4. Complementary and Integrative Medicine (CIM) CIM modalities generally emphasize a holistic ap- proach to health and well-being, addressing the in- terconnectedness of mind, body, and spirit. Several CIM modalities have gained recognition for their potential role in chronic pain management, includ- ing yoga, Tai Chi, acupuncture, and massage ther- apy [23]. 4.1 Yoga

Yoga, a multifaceted mind-body intervention, can enhance musculoskeletal flexibility, augment mus- cular strength, improve postural stability, and cul- tivate interceptive awareness. Its therapeutic effi- cacy for various chronic pain pathologies has been explored by a substantial body of empirical inves- tigations. Research consistently suggests that struc- tured yoga protocols may confer significant bene- fits in attenuating pain and improving functional capacity in individuals afflicted with chronic low back pain. Further studies have highlighted the benefits of yoga in other chronic pain conditions, such as osteoarthritis and fibromyalgia, demon- strating positive outcomes in terms of pain reduc- tion and health-related quality of life [24,25]. 4.2 Tai Chi Tai Chi, frequently described as "meditation in mo- tion", is a low-impact mind-body exercise that can significantly enhance proprioceptive balance, mus- culoskeletal flexibility, and neuromuscular coordi- nation. Empirical investigations have explored its therapeutic potential in chronic pain management, with emerging research suggesting its potential to reduce pain and improve functional outcomes in chronic pain conditions such as osteoarthritis and fibromyalgia. Further studies have highlighted the effects of Tai Chi on other chronic pain pheno- types, demonstrating positive outcomes with re- gard to pain reduction, ameliorated affective states, and improved health-related quality of life. How- ever, additional rigorous research is warranted to corroborate these preliminary findings and to delin- eate optimal Tai Chi protocols for diverse chronic pain aetiologies [26]. 4.3 Acupuncture Acupuncture is claimed to confer therapeutic ef- fects through the modulation of endogenous energy flow (Qi) and the promotion of endogenous opioid peptide release, thereby inducing systemic antino- ciception. This ancient therapeutic modality has been subjected to rigorous empirical scrutiny re- garding its role in chronic pain management, and select investigations have indicated that it may be effective in lowering pain intensity and improving functional status in patients with chronic pain con- ditions such as intractable lumbago, cervicalgia, and osteoarthritic arthralgia. Nevertheless, the ag- gregate evidence base for the effectiveness of acu- puncture in chronic pain remains heterogeneous, necessitating more rigorous methodological de- signs to definitively confirm these observations and

to determine the precise neurophysiological mech- anisms underpinning its therapeutic actions [27]. 4.4 Massage Therapy Various manual therapeutic techniques, including Swedish massage, deep tissue manipulation, and myofascial release, are employed within the do- main of massage therapy. This modality has been rigorously investigated for its potential benefits in chronic pain management. Empirical evidence sug- gests that massage therapy may be effective in at- tenuating pain and enhancing functional parame- ters in individuals with conditions such as chronic low back pain, cervicalgia, and fibromyalgia. Fur- thermore, studies have explored the effects of mas- sage therapy on other chronic pain phenotypes, finding positive outcomes in pain reduction, ame- liorated affective states, and reduced anxiety levels [28].

Discussion

The findings of this narrative review highlight the multifaceted nature of non-pharmacological inter- ventions in the management of chronic pain, demonstrating varying degrees of evidence for their efficacy across diverse conditions. The syn- thesized literature underscores the potential for these therapies to significantly impact pain inten- sity, functional capacity, and quality of life, along- side their generally favourable safety profiles. Physical therapies, particularly exercise therapy, are supported by robust evidence for their role in improving physical function and mitigating pain. The consistent findings across studies emphasize the importance of tailored exercise programs that address individual needs and limitations. Manual therapy, while showing promise for specific condi- tions such as chronic low back pain with techniques such as spinal manipulation, has more varied evi- dence for its broader application. Therapeutic mo- dalities may offer short-term relief, but for long- term chronic pain management, often lack the strong evidence base such as that observed for ex- ercise or manual therapy. The literature suggests that physical therapy programs are most effective when carefully tailored to the individual's specific needs, limitations, and pain condition. Further- more, combining different physical therapy tech- niques, such as manual therapy, exercise therapy, and modalities, may yield superior outcomes com- pared with monotherapy. Patient education is con- sistently highlighted as an essential component,

empowering patients with knowledge about their condition, the benefits of engagement, and self- management strategies. Progressive advancement of exercise programs is also critical as patient tol- erance and function improve [15]. Psychological therapies, notably cognitive behav- ioural therapy (CBT), emerge as critically im- portant in addressing the complex psychological and emotional dimensions of chronic pain. The ef- fectiveness of CBT in reducing pain intensity, im- proving function, and decreasing psychological distress is well-established across various chronic pain conditions. Mindfulness-based stress reduc- tion (MBSR) and acceptance and commitment therapy (ACT) also demonstrate considerable promise in fostering pain acceptance, enhancing psychological flexibility, and improving quality of life, even if direct pain reduction is not always the primary outcome. These therapies underscore the crucial link between mental well-being and the ex- perience of chronic pain. Complementary and integrative medicine (CIM) modalities present a holistic approach, with varying strengths of evidence. Yoga and Tai Chi show moderate evidence for reducing pain, improving function, and enhancing quality of life, often at- tributed to their integration of physical movement, breathing, and mindfulness. Acupuncture shows mixed results, with some evidence for specific pain conditions, but a need for more rigorous research to elucidate its mechanisms and broader effective- ness. Similarly, massage therapy offers moderate evidence for reducing pain and muscle tension, of- ten contributing to overall relaxation. The diverse mechanisms of these CIM therapies suggest their value as adjunctive treatments within a broader pain management strategy. A significant consensus exists regarding the para- mount importance of a multimodal approach to chronic pain management, advocating for the inte- gration of physical, psychological, and, where ap- propriate, CIM therapies. Exercise therapy and CBT are widely recognized as foundational com- ponents of effective chronic pain management strategies. There is also increasing recognition of the valuable role of mindfulness-based approaches, such as MBSR, in cultivating improved pain cop- ing mechanisms and acceptance among individuals with chronic pain [29,30]. However, areas of ongo- ing disagreement or uncertainty persist. These in-

clude determining the optimal specific interven- tions, such as identifying the most effective types of exercise for distinct pain conditions, establishing the long-term effectiveness of certain manual ther- apy techniques, and fully elucidating the precise mechanisms by which CIM modalities exert their therapeutic effects.

Study Limitations

This review is subject to several limitations that warrant acknowledgment. First, its scope was lim- ited to studies published in English within the past 25 years (2000-2024); this methodological choice may have inadvertently excluded some relevant re- search published in other languages or prior to this time-frame. Furthermore, while a comprehensive search strategy covered multiple databases, publi- cation bias remains a potential concern, as studies with negative or inconclusive results may be less likely to be published, potentially overestimating the effectiveness of some interventions. The narra- tive synthesis approach, while providing a broad overview of the literature, does not offer the same level of statistical rigor as a meta-analysis; it was therefore not possible to quantitatively assess the overall effect sizes of the different interventions. There was some variability in the quality of the in- cluded studies. While it was attempted to include only high-quality studies, some may have had methodological limitations, such as small sample sizes, lack of blinding, or unclear allocation con- cealment, which could have influenced their re- sults. The heterogeneity of study populations, en- compassing variations in the type of chronic pain, duration of pain, and comorbidities, presented chal- lenges in directly comparing and synthesizing find- ings across studies. Furthermore, the review fo- cused primarily on the effectiveness of non-phar- macological interventions and did not extensively address the cost-effectiveness or implementation challenges associated with these interventions. Fi- nally, the search and selection process, while sys- tematic, is inherently subject to the subjective judg- ment of the reviewers, and some relevant studies may have been inadvertently overlooked.

Conclusion

This narrative review provides a comprehensive overview of the current evidence for non-pharma- cological interventions in the management of

chronic pain. Physical therapies, including manual therapy and exercise therapy, are pivotal in improv- ing physical function and reducing pain, while psy- chological therapies, particularly CBT, are indis- pensable for addressing the psychological and emotional aspects of chronic pain. CIM modalities, such as yoga and Tai Chi, offer promising comple- mentary approaches. While the strength of evi- dence varies between different interventions, a multimodal approach integrating physical, psycho- logical, and CIM therapies is often recommended for optimal chronic pain management. List of Abbreviations: ACT: Acceptance and commitment therapy CBT: Cognitive behavioral therapy CIM: Complementary and Integrative Medicine MBSR: Mindfulness-based stress reduction OT: Occupational therapy RCT: Randomized controlled trial TENS: Transcutaneous electrical nerve stimulation

VII. REFERENCES 1. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. Eur J Pain. 2006;10(4):287- 333. 2. Institute of Medicine. Relieving pain in America: A blueprint for transforming pre- vention, care, education, and research. Na- tional Academies Press; 2011. 3. Goldberg DS, McGee SJ. Pain as a global public health priority. BMC Public Health . 2011;11:770. 4. Dydyk AM, Conermann T. Chronic Pain. [Updated 2024 May 6]. In: StatPearls [In- ternet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 553030/ 5. Turk DC, Okifuji A. Treatment of chronic pain patients: Clinical outcomes, cost-ef- fectiveness, and cost-benefits of multidisci- plinary pain management. Crit Rev Phys Rehabil Med . 2001;13(2):79-119. 6. Woolf CJ. What is this thing called pain? J Clin Invest . 2010;120(11):3742-3744. 7. Nicholson B, Verma S. Comorbidities in chronic pain. Pain Med . 2004;5(1):69-77. 8. Bair MJ, Robinson RL, Katon W. Depres- sion and anxiety in patients with chronic

pain. J Pain Symptom Manage. 2003;25(5):399-408. 9. Ambrose KR, Golightly YM. Physical ex- ercise as non-pharmacological treatment of chronic pain: Why and when. Best Pract Res Clin Rheumatol. 2015 Feb;29(1):120- 30. doi: 10.1016/j.berh.2015.04.022. Epub 2015 May 23. PMID: 26267006; PMCID: PMC4534717. 10. National Guideline Centre (UK). Evidence review for manual therapy for chronic pri- mary pain: Chronic pain (primary and sec- ondary) in over 16s: assessment of all chronic pain and management of chronic primary pain: Evidence review I. London: National Institute for Health and Care Ex- cellence (NICE); 2021 Apr. (NICE Guide- line, No. 193.) Available from: https://www.ncbi.nlm.nih.gov/books/NBK 569986/ 11. Jurecka A, Papież M, Skucińska P, Gądek A. Evaluating the effectiveness of soft tis- sue therapy in the treatment of disorders and postoperative conditions of the knee joint - A systematic review. J Clin Med. 2021 Dec 18;10(24):5944. doi: 10.3390/jcm10245944. PMID: 34945240; PMCID: PMC8704673. 12. Hayden JA, Ellis J, Ogilvie R, Malmivaara A, van Tulder MW. Exercise therapy for chronic low back pain. Cochrane Database Syst Rev . 2021 Sep 28;9(9):CD009790. doi: 10.1002/14651858.CD009790.pub2. PMID: 34580864; PMCID: PMC8477273. 13. Johns LD. Nonthermal effects of therapeu- tic ultrasound: the frequency resonance hy- pothesis. J Athl Train . 2002 Jul;37(3):293- 9. PMID: 16558674; PMCID: PMC164359. 14. Munari D, Serina A, Leonardelli A, et al. Effects of deep heating modalities on the morphological and elastic properties of the non-insertional region of achilles tendon: a pilot study. Int J Hyperthermia . 2022;39(1):222-228. doi:10.1080/02656736.2022.2026497 15. Canadian Agency for Drugs and Technolo- gies in Health. Physical therapy treatments for chronic non-cancer pain: A review of guidelines [Internet]. Ottawa (ON): Cana- dian Agency for Drugs and Technologies in

Health; 2016 Nov 10. Appendix 4, Sum- mary of recommendations by source. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 409571/ [Cited 2025 Aug 18]. 16. Lagueux É, Dépelteau A, Masse J. Occupa- tional therapy's unique contribution to chronic pain management: a scoping re- view. Pain Res Manag . 2018 Nov 12;2018:5378451. doi: 10.1155/2018/5378451. PMID: 30538795; PMCID: PMC6260403. 17. Physiopedia. Joint protection principles [Internet]. 2020 Oct 29 [cited 2025 Feb 8]. Available from: https://www.physio-pe- dia.com/index.php?title=Joint_Protec- tion_Principles&oldid=257840 18. Williams ACC, Fisher E, Hearn L, Ec- cleston C. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2020 Aug 12;8(8):CD007407. doi: 10.1002/14651858.CD007407.pub4. PMID: 32794606; PMCID: PMC7437545. 19. Institute for Quality and Efficiency in Health Care (IQWiG). In brief: Cognitive behavioral therapy (CBT) [Updated 2022 Jun 2]. In: InformedHealth.org [Internet]. Cologne (Germany): Institute for Quality and Efficiency in Health Care (IQWiG); 2006-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 279297/ 20. Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive be- havioral therapy: a review of meta-anal- yses. Cognit Ther Res. 2012 Oct 1;36(5):427-440. doi: 10.1007/s10608-012- 9476-1. Epub 2012 Jul 31. PMID: 23459093; PMCID: PMC3584580. 21. Hofmann SG, Gómez AF. Mindfulness- based interventions for anxiety and depres- sion. Psychiatr Clin North Am. 2017 Dec;40(4):739-749. doi: 10.1016/j.psc.2017.08.008. Epub 2017 Sep 18. PMID: 29080597; PMCID: PMC5679245. 22. Hughes LS, Clark J, Colclough JA, Dale E, McMillan D. Acceptance and commitment therapy (ACT) for chronic pain: a system- atic review and meta-analysis. Clin J Pain .

2017;33(6):552-568. doi:10.1097/AJP.0000000000000425 23. Tabish SA. Complementary and alternative healthcare: is it evidence-based? Int J Health Sci (Qassim). 2008 Jan;2(1):V-IX. PMID: 21475465; PMCID: PMC3068720. 24. Woodyard C. Exploring the therapeutic ef- fects of yoga and its ability to increase qual- ity of life. Int J Yoga. 2011 Jul;4(2):49-54. doi: 10.4103/0973-6131.85485. PMID: 22022122; PMCID: PMC3193654. 25. Chen Q. Neurobiological and anti-aging benefits of yoga: a comprehensive review of recent advances in non-pharmacological therapy. Exp Gerontol. 2024;196:112550. doi:10.1016/j.exger.2024.112550 26. Kuramoto AM. Therapeutic benefits of Tai Chi exercise: research review. WMJ . 2006;105(7):42-46. 27. Van Hal M, Dydyk AM, Green MS. Acu- puncture. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK 532287/ 28. Field T. Massage therapy research review. Complement Ther Clin Pract . 2016;24:19- 31. doi:10.1016/j.ctcp.2016.04.005 29. Morcillo-Muñoz Y, Castellano MHJ, Ex- posito FJD, Sanchez-Guarnido AJ, Alcan- tara MG, Baena-Parejo MI. Multimodal in- terventions to improve the management of chronic non-malignant pain in primary care using participatory research. Clin Pract. 2021 Aug 26;11(3):561-581. doi: 10.3390/clinpract11030072. PMID: 34449567; PMCID: PMC8395459. 30. Nijs J, Malfliet A, Roose E, Lahousse A, van Bogaert W, Johansson E, et al. Person- alized multimodal lifestyle intervention as the best-evidenced treatment for chronic pain: state-of-the-art clinical perspective. Journal of Clinical Medicine. 2024; 13(3):644. https://doi.org/10.3390/jcm13030644